I983 Form Fillable PDF Details

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Form Name I983 Form Fillable
Form Length 7 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 1 min 45 sec
Other names i983 sample filled, i983 examples for engineering, sample i 983 form filled, i983 fillable form no download needed

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SAMPLE I-983 FORM

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement

TRAINING PLAN FOR STEM OPT STUDENTS

Science, Technology, Engineering & Mathematics (STEM) Optional Practical Training (OPT)

 

 

 

 

 

 

OMB CONTROL NO. 1653-0054

 

 

 

 

 

 

EXPIRATION DATE: 03/31/2019

 

 

 

 

 

 

 

 

SECTION 1: STUDENT INFORMATION (Completed by Student)

 

 

Student Name (Surname/Primary Name, Given Name):

 

Student Email Address:

 

 

 

LAST NAME, FIRST NAME

 

BOB.SMITH@SJSU.EDU

 

 

 

 

 

 

 

 

Name of School Recommending

Name of School Where STEM

 

SEVIS School Code of School Recommending STEM OPT (including 3-digit

 

STEM OPT:

Degree Was Earned:

 

suffix):

 

 

 

 

 

 

 

 

San Jose State University

San Jose State University

 

SFR214F00627000

 

 

 

 

 

 

 

 

Designated School Official (DSO) Name and Contact Information:

 

Student SEVIS ID No.:

STEM OPT Requested Period: (mm-dd-yyyy)

 

KHIM LOK

 

 

N0000000000

 

 

 

(408)924-5920

 

 

(This number is

Day after your EAD expires

24 months later

 

 

 

located on the top

From: _______________ To: _______________

 

KHIM.LOK@SJSU.EDU

 

 

 

 

 

left corner, 1st page)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Qualifying Major and Classification of Instructional Programs (CIP)

Code: 00.0000 -This number can be found where your major is located.

 

 

 

Bachelors, Masters, PhD, etc.

 

 

 

Level/Type of Qualifying Degree: _________________________________________________

 

 

date when your degree was awarded

Date Aw arded: (mm-dd-yyyy) ________________________________

Based on Prior Degree?Yes

No unless you are basing your application on a different degree level earner in the U.S. within the past 5 years.

xxx - xxx - xxx

Employment Authorization Number: _______________________________

Found under "USCIS #" on EAD card

SECTION 2: STUDENT CERTIFICATION

Ideclare and affirm under penalty of perjury that the statements and information made herein are true and correct to the best of my know ledge, information and belief. I understand that the law provides severe penalties forknowingly and willfully falsifying or concealing a material fact, or using any false document in the submission of this form.

Icertify that:

1.I have review ed, understand, and will adhere to this Training Plan for STEM OPT Students (“Plan”);

2.I w ill notify the DSO at the earliest available opportunity if I believe that my employer is not providing me w ith appropriate training as delineated on this Plan;

3.I understand that the Department of Homeland Security (DHS) may deny, revoke, or terminate the STEM OPT of students whomDHS determines are not engaging in OPT in compliance w ith the law , including the STEM OPT of students w ho are not, or w hoseemployers are not, complying w ith this Plan;

4.My practical training opportunity is directly related to the STEM degree that qualifies me for the STEM OPT extension; and

5.I w ill notify the DSO at the earliest available opportunity regarding any material changes to or deviations fromthis Plan, including but not limited to, any change of Employer Identification Number resulting froma corporate restructuring, any nontrivial reduction in compensation fromthe amount previously submitted on the Plan that is not tied to a reduction in hours w orked, any significant decrease in hours per w eek that I engage in a STEM training opportunity, and any decrease in hours below the 20-hours-per-week minimum required under this rule.

Signature of Student:

Printed Name of Student:

 

Date: (mm-dd-yyyy) ______________

Form I-983 (1/16)

Page 1 of 7

SECTION 3: EMPLOYER INFORMATION (Completed by Employer)

Employer Name:

 

 

Street Address:

 

 

Suite:

 

 

 

 

 

 

 

Employer Website URL:

 

 

City:

State:

ZIP Code:

 

 

 

 

 

Employer ID Number (EIN):

Number of Full-Time

North American Industry Classification System(NAICS) Code:

 

Employees in U.S.

 

 

 

 

 

 

 

 

 

 

OPT Hours Per Week (must be at least 20

Compensation

 

 

 

 

hours/week):

A.

Salary Amount and Frequency: ______________________________________

 

 

B.

Other Compensation (Type and Estimated Amount or Value):

 

 

 

1.

_______________________________________________________________

Start Date of Employment:

2.

_______________________________________________________________

 

(mm-dd-yyyy)_________________________

3.

_______________________________________________________________

 

 

 

 

 

 

 

4.

_______________________________________________________________

 

 

 

 

 

 

 

SECTION 4: EMPLOYER CERTIFICATION

I declare and affirm under penalty of perjury that the statements and information made herein are true and correct to the best of my know ledge,

information and belief. I understand that the law provides severe penalties forknowingly and willfully falsifying or concealing a material fact, or using any false document in the submission of this form.

I certify on behalf of the employer that this Training Plan for STEM OPT Students (“Plan”) is approved and that:

1.I have review ed and understand this Plan, and I w ill ensure that the supervising Official follow s this Plan;

2.I w ill notify the DSO at the earliest available opportunity regarding any material changes to this Plan, including but not limited to, any change of Employer Identification Number resulting froma corporate restructuring, any reduction in compensation fromthe amount previously submitted on the Plan that is not tied to a reduction in hours worked, any significant decrease in hours per week that a student engages in a STEM training opportunity, and any decrease in hours below the 20-hours-per-week minimum required under this rule;

3.Within five business days of the termination or departure of the student during the authorized period of OPT, I w ill report such termination or departure to the DSO (Note: business days do not include federal holidays or w eekend days; and an employer shall consider a student to have departed w hen the employer know s the student has left the practical training opportunity, or w hen the student has not reported for practical training for a period of five consecutive business days without the consent of the employer); and

4.I w ill adhere to all applicable regulatory provisions that govern this program(see 8 CFR Part 214), which include, but are not limited to, the follow ing:

a.The student’s practical training opportunity is directlyrelated to the STEM degree that qualifies the student for the STEM OPT extension, and the position offered to the student achieves the objectives of his or her participation in this training program;

b.The student will receive on-site supervision and training, consistent w ith this Plan, by experienced and know ledgeable staff;

c.The employer has sufficient resources and personnel to provide the specified training programset forth in this Plan, and the employer is prepared to implement that program, including at the location(s) identified in this Plan;

d.The student on a STEM OPT extension will not replace a full- or part-time, temporary or permanent U.S. w orker. The terms and conditions of the STEM practical training opportunity—including duties, hours, and compensation—are commensurate with the terms and conditions applicable to the employer’s similarly situated U.S. w orkers or, if the employer does not employ and has not recently employed more than tw o similarly situated U.S. w orkers in the area of employment, the terms and conditions of other similarly situated U.S. w orkers in the area of employment; and

e.The training conducted pursuant to this Plan complies w ith all applicable Federal and State requirements relating to employment.

Note:DHS may, at its discretion, conducta site visit of the employer to ensure that program requirements are beingmet, includingthat the employer possesses and maintains the abilityand resources to provide structured and guided work-based learningexperiences consistent with this Plan.

Signature of Employer Official w ith Signatory Authority: ________________________________________________________________________

Printed Name and Title of Employer Official w ith Signatory Authority: _____________________________________________________________

Date: (mm-dd-yyyy) ______________ Printed Name of Employing Organization: _____________________________________________________

Form I-983 (1/16)

Page 2 of 7

SECTION 5: TRAINING PLAN FOR STEM OPT STUDENTS (Completed by Student and Employer)

Student Name (Surname/Primary Name, Given Name):

Employer Name:

EMPLOYER SITE INFORMATION

Site Name:

Name of Official:

Site Address (Street, City, State, ZIP):

Official’s Title:

Official’s Email:

Official’s Phone Number:

Note: for the remaining fieldsin thissection, employerswho already have aninternal/pre-existingtrainingplaninplace may fill in the details based on that plan.

Student Role: Describe the student's role w iththeemployer and how that role is directly related to enhancing the student’s knowledge obtained through his or her qualifying STEM degree.

Form I-983 (1/16)

Page 3 of 7

Goals and Objectives: Describe how the assignment(s) w ith the employer w ill help the student achieve his or her specific objectives for work-based learning related to his or her STEM degree. The description must both specify the student’s goals regarding specific know ledge, skills, or techniques as w ell as the means by w hich they w ill be achieved.

Employer Oversight: Explain how the employer provides oversight and supervision of individuals filling positions such as that being filled by the named F-1 student. If the employer has a training program or related policy in place that controls such oversight and supervision, please describe.

Measures and Assessments: Explain how the employer measures and confirms w hether individuals filling positions such as that being filled by the named F-1 student are acquiring new know ledge and skills. If the employer has a training program or related policy in place that controls such measures and assessments, please describe.

Additional Remarks (optional): Provide additional information pertinent to the Plan.

SECTION 6: EMPLOYER OFFICIAL CERTIFICATION

Ideclare and affirm under penalty of perjury that the statements and information made herein are true and correct to the best of my know ledge, information and belief. I understand that the law provides severe penalties forknowingly and willfully falsifying or concealing a material fact, or using any false document in the submission of this form.

Employer Officialwith Signatory Authority- I certify that:

1.I have review ed, understand, and will follow this Training Plan for STEM OPT Students (Plan);

2.I w ill conduct the required periodic evaluations of the student;*

3.I w ill adhere to all applicable regulatory provisions that govern this program(see 8 CFR Part 214.2(f)(10)(ii)); and

4.I w ill notify the DSO regarding any material changes to or material deviations fromthis Plan at the earliest available opportunity, including if I believe the student is not receiving appropriate training as delineated in this Plan.

Signature of Employer Official w ith Signatory Authority: ____________________________________________________________

Printed Name and Title of Employer Official with Signatory Authority:____________________________ Date: (mm-dd-yyyy) __________________

PRIVACY ACT STATEMENT

Form I-983 (1/16)

Page 4 of 7

AUTHORITIES: Section 101(a)(15)(F) of the Immigration and Nationality Act of 1952, as amended (INA), 8 U.S.C. 1101(a)(15)(F), Section 641 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), Pub. L. 104-208, Div. C, 110 Stat. 3009-546 (codified at 8 U.S.C. 1372), Section 502 of the Enhanced Border Security and Visa Entry Reform Act of 2002, Pub. L. 107-173, 116 Stat. 543 (codified at 8 U.S.C. 1762) and Homeland Security Presidential Directive No. 2 (HSPD-2), authorize U.S. Immigration and Customs Enforcement (ICE) to collect the information requested in this form.

PURPOSE: The information collection on this form is used to assist in the administration of the STEM Optional Practical Training (OPT) extension so

that Designated School Officials (DSO) can properly recommend the Student for and review and help coordinate his or her STEM optional practical training opportunity.

ROUTINE USES: The information collected on this formmay be shared w ith: the individuals w ho signed the Plan, relevant DSOs acting as liaisons w ith the DHS, Federal, State, local, or foreign government entities for law enforcement purposes, Members of Congress in response to requests on the Student’s behalf, or as otherw ise authorized pursuant to its published Privacy Act systemof records notice - Privacy Act of 1974: U.S.

Immigration and Customs Enforcement, DHS/ICE-001 Student and Exchange Visitor Information System (SEVIS) System of Records (https://www.dhs.gov/system-records-notices-sorns).

DISCLOSURE: The information you provide is voluntary. How ever, failure to provide the information requested on this formmay delay or prevent participation in a STEM OPT opportunity.

PAPERWORK REDUCTION ACT

The public reporting burden for this collection of information is estimated to average 7.5 hours per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid Office of Management and Budget (OMB) control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, send them to: U . S . Immigration and Customs Enforcement, Office of Policy, 500 12th Street SW, Washington, D.C. 20536

*See evaluation forms that follow for student’s first evaluation, to occur before the one year anniversary of the start date of the student’s STEM OPT employment authorization, and final program evaluation.

Form I-983 (1/16)

Page 5 of 7

EVALUATION ON STUDENT PROGRESS

Provide a self-evaluation of your performance, using the measures previously identified, in applying and acquiring new know ledge, skills, and competencies identified in the Training Plan for STEM OPT Students. Discuss accomplishments, successful projects, overall contributions, etc., during this review period. Address whether there are any modifications to the objectives and goals for projects, or new areas for skill and competency development.

Range of Evaluation Dates: (mm-dd-yyyy): From __________ To __________

Must be submitted within the first 12 months of STEM Employment

Signature of Student: ___________________________________________________________________________________________________

Printed Name of Student: _____________________________________________________________ Date: (mm-dd-yyyy) ______________

Signature of Employer Official w ith Signatory

Authority:__________________________________________________________________________________

Printed Name of Employer Official with Signatory Authority: _______________________________________ Date: (mm-dd-yyyy) ______________

Form I-983 (1/16)

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FINAL EVALUATION ON STUDENT PROGRESS

Provide a self-evaluation of your performance, using the measures previously identified, in applying and acquiring new know ledge, skills, and competencies identified in the Training Plan for STEM OPT Students. Discuss accomplishments, successful projects, overall contributions, etc., during this review period. Address whether there are any modifications to the objectives and goals for projects, or new areas for skill and competency development.

Range of Evaluation Dates: (mm-dd-yyyy) From __________ To __________

To be submitted at the end of employment

Signature of Student: ___________________________________________________________________________________________________

Printed Name of Student: _____________________________________________________________

Date: (mm-dd-yyyy) ______________

Signature of Employer Official w ith Signatory Authority:________________________________________________________________

Printed Name of Employer Official with Signatory Authority: ______________________________________

Date: (mm-dd-yyyy) ______________

Form I-983 (1/16)

Page 7 of 7

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